A Perfect Storm: Job Stress, Drug Access & Code of Silence Feed Addiction in Health Professionals
Every day for four years now, pharmacist Jake Nichols calls the testing lab to see if he’s been chosen for a random drug screen. It’s a condition of his state-mandated recovery program for a merciless prescription drug addiction that led to job losses, severe family hardship and 513 felony counts.
“I was very lucky,” Nichols says. “I truly had a judge who saw an addict standing in front of him and not a drug dealer or someone with other motives.”
The downfall has been humbling for Nichols, whose high-profile career included managing the outpatient drug formulary at Boston Medical Center and serving as Director of Clinical Affairs for the University of Massachusetts Medical School.
For 15 years, Nichols was enslaved by his disease. He’d quietly steal a handful of pills from bathroom medicine cabinets when visiting friends and relatives. Or feign back injuries and Attention Deficit Hyperactivity Disorder (ADHD) so that he could obtain and then snort potent narcotics and stimulants.
Intense workloads and a pervasive family history of drug and alcohol addiction compounded Nichols’ obsession. He progressed to building a personal drug stash from rogue pharmacies overseas, then resorted to more brazen tactics.
“My tolerance was growing and the sources that I used before weren’t holding me,” he recalls. “At this point, I started to write fake prescriptions. I was writing for stimulants, opioids and also benzodiazepines like Ativan to help me sleep.”
Nichols was exposed in April 2010, when another pharmacist discovered him diverting large quantities of narcotics from the oncology pharmacy where they worked. Nichols surrendered his license, and after several addiction relapses, he achieved sobriety and has remained drug-free since July 26, 2010.
“I stepped back, I looked at my life and said, ‘I’m young, I have two children, and I have a shot at fixing this. And I had to decide at that point whether I wanted to get my life back by being serious about recovery.”
As Nichols can attest, medical professionals are not immune to the disease of addiction – posing serious risk to themselves and the patients in their care.
“It’s certainly an occupational hazard when potentially addictive substances are something you are constantly doling out,” says Paula Davies Scimeca, RN, clinical nurse specialist for behavioral sciences at Staten Island University Hospital in New York.
More than 18,000 disciplinary cases involving nurses diverting drugs were reviewed by state nursing boards between 1996 and 2006, says Scimeca, who has been devoted to the study of addiction in nurses since 2003 and is the author of “Unbecoming a Nurse: Bypassing the Hidden Chemical Dependency Trap.”
“Generally speaking, the nurses that get into trouble are nurses that have graduated in the top third of their class,” Scimeca says. “We are talking about the movers and shakers.”
National studies estimate that one in 10 healthcare practitioners will have a substance abuse problem at some point in their careers – a rate that mirrors the general population.
But the real depth of the problem is unknown – and likely underestimated, experts say. A conspiracy of silence, fear of getting caught, fear of litigation and the stigma of addiction keep many practitioners from admitting or reporting substance abuse. Unlike other safety-sensitive industries, there’s no universal drug testing for healthcare workers. And the access and drug knowledge that medical practitioners have puts them at greater occupational risk for addiction.
“You’re kind of looking at a perfect storm here,” says Brian Fingerson, RPh, who oversees Kentucky’s monitoring program for impaired professionals in nine licensed occupations – including dentists, pharmacists and physical therapists.
“Number one, you’ve got access to drugs. You may have a family history, you’re in a stressful profession.” “Pharmacists,” Fingerson notes, “are taught that they have to be perfect, that you cannot make a mistake or you will kill somebody. Then you have education – pharmacists are the drug experts so the feeling is, ‘I know all about it, how can it hurt me?”’
In her interviews with dozens of recovering nurses, Scimeca chronicles the unique job risks that can lead to addiction. One nurse anesthetist who never had a history of drug or alcohol problems became addicted to Propofol, a powerful anesthesia sedative.
“She wound up having to surrender her license and was very close to death a couple times,” Scimeca says. “She talks about how anyone who knew her said, ‘If it could happen to you, it could happen to anyone’ because she had no (addiction) history.” The forward to Scimeca’s book was written by the surviving daughter of a former President of the American Association of Nurse Anesthetists, who died of a drug overdose at age 50.
“There are too many nurses who are getting a license in 2012 and surrendering it in 2014,” Scimeca says. “There are too many nurses who are still dying of an overdose in hospital staff bathrooms.”
Denial Runs Deep
Denial is typical in the culture of addiction, and it’s no different for well-educated medical professionals.
When there is credible evidence of a physician showing signs of addiction, the doctor nearly always rejects the concerns, says Gregory Skipper, M.D., who has worked with hundreds of impaired physicians as the former director of Alabama’s Physician Health Program and is currently Director of Professionals Health Services for Promises Treatment Centers .
“They all say, ‘I don’t have a problem’ when I tell them there have been complaints,” says Skipper. “And I say, ‘Good. Let’s get a good evaluation and document it.”’
As part of his assessment, one physician recently took a polygraph test to determine how often he was taking his child’s prescription amphetamines (he had admitted to doing so once). The evaluation, Skipper says, helps doctors get past denial, shame and dishonesty so they can begin the process of recovery.
According to “The Addicted Physician,” a seminal article in 2010 by Marvin D. Seppala, M.D., and Keith H. Berge, M.D.:
“Physicians seldom enter treatment voluntarily and at first will rarely describe their history of substance use accurately. When they are in a state of denial, they have little incentive to admit to a problem, and they are afraid and anxious about the possibility of losing their job and license. They are also driven by the continued pursuit of drugs.”
Denial among nurses is often fueled by invincible attitudes about pharmaceutical knowledge, Scimeca says. Since nurses routinely medicate their patients safely and effectively, some practitioners assume they can do the same for themselves.
“A lot of medical professionals get into trouble because they are self-medicating a physical or emotional condition,” Scimeca says, noting “there is no bona fide caregiver there to watch the reaction and to be monitoring the frequency of the doses and the actual dose.”
Saving Lives & Careers
Most states offer peer assistance and recovery monitoring programs to protect the public and help impaired professionals. These specialized rehab programs typically have high success rates, since treatment is intensive and peer monitoring continues for several years.
Nichols, the Massachusetts pharmacist, is now in his fourth year of a five-year state program for recovering healthcare professionals. In addition to random drug tests, Nichols attends at least four 12-step meetings each week, sees a substance abuse counselor, attends a professional support group once a week and submits documentation on his recovery.
“These programs can be a lifesaver,” he says. “The structure was necessary for me to maintain my sobriety.”
Nichols is now working as an educator and medical science liaison for chemical dependency treatments. He says he’ll petition the pharmacy board to re-instate his license next year when he completes the recovery program, but knows there are no guarantees.
“I decided after a great deal of thinking to go public with my addiction because I felt that other people needed to hear the story,” Nichols says. “Too many people had said to me, ‘you’re the last person I would expect that (addiction) from. So I felt it was my duty to put a different face on what people see as an addict.”
A former emergency room nurse – who was taking 60 Vicodin pills a day, and self-injecting the narcotics Demerol and Dilaudid – says the state nursing program freed her. The conditions were ironclad: she had to attend a daily 12-step meeting for 1 ½ years, submit to random drug tests for 3 ½ years, attend weekly nurse support groups, undergo regular evaluations by a diversion committee, and be supervised by a work-site monitor once she was allowed to re-enter nursing.
“The nurse support groups were a type of mirror for me. I saw a lot of victimization and denial. Many of the nurses didn’t believe they had a problem with addiction, which only amplified my sense of gratitude that I was sober and had the diversion program to protect me from myself . . . My life began to take on a new dimension, better than anything that I could have planned for myself . . . I came to realize that it wasn’t nursing that betrayed me; it was my addiction.”
“I will be forever indebted to the nursing board for offering me the opportunity to not only salvage my license, but to salvage my life. Through the very structured program of diversion, I adopted, what I call “good recovery habits.” Now, over seven years later, not a day goes by that I am not immensely grateful to be sober and to have a program of recovery that I am deeply involved in.”
by Paula Davies Scimeca, RN, MS © 2010 (Excerpted with permission)
Models of Success
Physician Health Programs are the most standardized of the peer assistance programs and have remarkable success rates. A study of 904 physicians enrolled in 16 Physician Health Programs revealed that doctors had a 79 percent rate of abstinence from alcohol or drugs over a seven-year period, Skipper says. And of the 21 percent of physicians who relapsed, two-thirds did not have a second relapse, he noted. In the general population, 40-60 percent of people relapse in the first year after rehab treatment, according to the National Institute on Drug Abuse (NIDA).
Skipper attributes the physicians’ high recovery rates to the long-term case management under the five-year program. “It’s because they’re being followed carefully and they know ahead of time there’s going to be consequences.
“It’s clearly spelled out in the contract what the consequence will be if they miss tests or have a positive drug screen or miss therapy appointments or don’t get in a worksite monitor report,” Skipper says. “The most reasonable consequence in my opinion is to have to stop working and be re-evaluated. But in some cases, there can be more dire consequences such as the loss of a medical license, or termination from their job.”
Fingerson, the President of Kentucky Professionals Recovery Network (KYPRN), says he mirrors the structure of the Physician Health Program, with similar results.
An estimated 75 percent of licensed professionals enrolled in the Kentucky program do not relapse during the five-year period of monitoring, Fingerson says.
“For those that do have a relapse, the benefit of having this type of monitoring program is that we can intervene on them really quickly to get them back into treatment and also protect the public,” he says.
Most of Fingerson’s clients (80 percent) are referred by state licensing boards after a complaint or investigation regarding substance abuse.
“My primary job after they get out of treatment is to make sure that they maintain their path of recovery,” Fingerson says. “They cannot imbibe in any mind or mood altering drugs . . . they can’t even take something for a cough or cold unless they call me first because if it shows up in a drug screen, it gets reported.”
The intensive treatment and monitoring is necessary in these specialized programs, Skipper says, because ultimately patient lives are at stake. Most rehab programs couldn’t provide the same level of depth in determining the scope of the practitioner’s disease; for example, Skipper says his team recently interviewed 12 members of a hospital and medical staff regarding an impaired physician. Variable, personalized treatment is a key component of effective programs for healthcare professionals, he says. One physician may need more help with trauma or pain issues and another, with a sex addiction.
“For a health professionals program, it needs to be customized to meet all their needs,” Skipper says. “When you send a heart surgeon back to work, the medical board doesn’t want to know that he just did his 28 days. They want to know that he’s fit to go back to surgery and is not going to have a relapse that’s going to endanger patients. We put a lot of effort into making sure all the bases are covered.”